CPT codes 43235-43259 have been placed in the new EGD subsection. These codes have been revised to describe flexible transoral EGD and include five new codes, revision and renumbering of several existing codes and the deletion of two codes.

Additionally, the following qualification to the definition of EGD has been included in the new EGD Guideline language to clarify the appropriate use of modifiers -52 and -53:

To report esophagogastroscopy where the duodenum is deliberately not examined [e.g., judged clinically not pertinent], or because significant situations preclude such exam [e.g., significant gastric retention precludes safe exam of duodenum], append modifier 52 if repeat examination is not planned, or modifier 53 if repeat examination is planned)

what is EGD

ESOPHAGOGASTRODUODENOSCOPY (EGD)

EGD is a procedure that enables your physician to examine the lining of the upper part of your gastrointestinal tract, which is the esophagus, stomach, and duodenum using a thin flexible tube with its own lens and light source.

What is an Upper Endoscopy?

Upper Endoscopy (also known as an upper GI endoscopy, esophagogastroduodenoscopy [EGD], or panendoscopy) is a procedure that enables your physician to examine the lining of the upper part of your gastrointestinal tract, i.e., the esophagus (swallowing tube), stomach, and duodenum (first portion of the small intestine) using a thin flexible tube with its own lens and light source.

EGD - How to prepare

EGD

Esophagogastroduodenoscopy, or EGD, (also known as upper GI endoscopy), is the examination of the upper digestive tract. This minimally invasive procedure is used to diagnose unexplained anemia, persistent dyspepsia (patients over 40 years old), dysphagia (difficulty swallowing), heartburn and chronic acid reflex, odynophagia (painful swallowing), and upper gastrointestinal bleeding. An EGD enables your doctor to examine your upper digestive tract for abnormalities using an endoscope.

PREP PROCESS

Do not eat food for at least 4 to 6 hours before the procedure. Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. You may need to stop these medications before the procedure.

PROCEDURE

The test lasts 5 to 20 minutes. The patient may receive moderate sedation or topical anesthesia on their oropharynx (part of the pharynx that reaches from the uvula to the hyoid bone). The patient lies on their left side on the exam table with their head bent forward during the procedure.

A mouth-guard is placed between the teeth to prevent the patient from biting on the endoscope. If you wear dentures you will be asked to remove them prior to the procedure.

The endoscope is passed over the tongue and into the oropharynx. The endoscope is guided to the stomach and examines the first and second parts of the duodenum (small intestine).

SIDE EFFECTS AND RISKS

The main risks are infection, bleeding and perforation. The risk is increased when a biopsy or other intervention is performed. Patients who are allergic to or sensitive to medications, contrast dyes, iodine, shellfish, or latex should notify their physician.

If you are pregnant or suspect that you are pregnant, you should notify your physician. Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

Coverage Indications, Limitations, and/or Medical Necessity

Upper intestinal endoscopy is performed with a lighted, flexible, fiberoptic instrument passed through the cricopharynx. The patient receives conscious sedation. A topical anesthetic is sometimes applied to the posterior pharynx.

Direct visualization of the entire esophagus, stomach, and duodenum (to the junction of the second and third portions) can be accomplished easily with modern instruments that are less than 12mm in diameter.

Esophagogastroduodenoscopy (EGD) is a technique utilized to examine, obtain samples, and in some instances, to treat pathological conditions.

A diagnostic EGD allows the examiner to visualize abnormalities detectable by the technique and to photograph, biopsy, and/or remove lesions as appropriate.

The purpose of the therapeutic EGD is to manage hemorrhage; remove foreign bodies and neoplastic growths; to relieve obstruction due to stricture, malignancy, or other causes through dilatation or the placement of stents; and to assist in the placement of percutaneous gastrostomy tubes.

EGD(s)will be considered medically reasonable and necessary under the following diagnostic conditions:

Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes and hemostatic injections into or around the bleeding vessels are both effective therapy for acute bleeding.

Foreign body removal from the stomach or esophagus is usually successful with these flexible instruments. The foreign bodies can be retrieved by either of two methods. The first method is to capture the foreign body with a snare device/grasping forceps and pull the item out with the endoscope.

The second method is accomplished by piecemeal destruction and pushing the bolus through the esophagus into the stomach.

Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices requires, on the average, five sclerotherapy sessions, with multiple injections given during each session.

Dilatation of strictures may be accomplished with a balloon placed through the endoscope and inflated using hydrostatic pressure. Bougies are rubber dilators available in various sizes up to approximately 2.0cm. Plastic bougies and other dilating probes are usually passed over a guide wire.

This procedure involves placing the guide wire into the stomach through the endoscope. The endoscope is then withdrawn leaving the guide wire in place. The dilating probes and plastic bougies are then passed over the guide wire.

After the largest dilator is used, the dilator and guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has been established in patients exhibiting dysphagia.

The goal in most cases is a lumenal diameter of 16-17mm which allows passage of solid food. A series of dilators may be passed over the guide wire to reach the goal of therapy.

Follow-up EGD(s)will be considered medically reasonable and necessary for the following indications:

Biopsy surveillance of patients with Barrett’s esophagus every 12 to 24 months. However, if dysplasia is present, earlier surveillance intervals of from three to six months may be required;

Follow-up of gastric ulcers to healing or satisfaction that they are benign;

EGD is generally contraindicated for patients with recent myocardial infarction.

Guide Wire and Dilation

The EGD family includes a code for insertion of guide wire followed by dilation over guide wire. Insertion of guide wire code 43248 has been revised to describe passage of dilator(s) over a guide wire rather than dilation. Codes 43248 and 43249 (dilation codes) should not be reported with codes 43266 and 43270, as these codes (stent, ablation) include dilation.

Endoscopic Ultrasound (EUS)

Endoscopic ultrasound (EUS) examination codes 43237 and 43238 have been revised to describe EUS limited to the esophagus, stomach or duodenum and adjacent structures.

Endoscopic ultrasound codes 43242 and 43259 have been revised to include examination of a surgically altered stomach where the jejunum is examined distal to the anastomosis. Clarification language has been included to address the extent of performance of the EUS examination as distinguished from the extent of the endoscopic visualization.

Pseudocyst Drainage

In addition to transmural drainage of pseudocyst as described in the current code 43240, EGD with transmural drainage of pseudocyst has been revised to specify that it includes endoscopic ultrasound, transmural drainage and placement of stent(s) to facilitate drainage, when performed.

Dilation Procedures

Dilation procedure codes have been added, revised and deleted to better describe current practice.

EGD code 43249 has been revised to specify transendoscopic balloon dilation of less than 30 mm in diameter. Code 43233 (>30mm balloon, e.g., achalasia) includes fluoroscopic guidance, when used. Code 43245 has been revised to describe dilation of gastric/duodenal stricture(s) and the guide wire example has been removed from the examples in parentheses. Code 43233 includes moderate sedation, as indicated by the moderate sedation symbol.

Control of Bleeding

The parentheticals for code 43255, EGD with control of bleeding code 43255 have been revised. Code 43255 should not be reported for treatment of esophageal/gastric varices, which are reported with more specific codes 43243 (sclerotherapy) or 43244 (banding). Code 43236, submucosal injection, would also not be reported if injection was part of the control of bleeding procedure.

Balloon Dilation of Esophagus

EGD code 43233 (out of sequence) has been established to report balloon dilation of 30 mm in diameter or larger. This dilation procedure includes fluoroscopic guidance, when used.

Endoscopic Mucosal Resection

Code 43254 has been established to report endoscopic mucosal resection (EMR) with EGD. Code 43254 includes removal of tumor(s), polyp(s) or other lesion(s) by snare technique (43251); directed submucosal injection(s) (43236); and band ligation (43254), so these services are not separately reportable when performed on the same lesion during the same session.

Biopsy (43239) performed on the same lesion as EMR is not separately reportable. Code 43254 includes moderate sedation, as indicated by the moderate sedation symbol.

Ultrasound-Guided Injections / Placement of Fiducial Markers

Code 43253 has been established to describe ultrasound-guide d transmural injection of substances (e.g., celiac axis injection) or fiducial markers. This code includes endoscopic ultrasound (EUS) of the esophagus, stomach, and either the duodenum or a surgically-altered stomach where the jejunum is examined distal to the anastomosis.

Ablation of Tumors A new code has been established for EGD with ablation (43270). The new code includes pre- and post-dilation and guide wire passage when performed. Separate reporting of pre- or post-dilation or guide wire passage when performing ablation of the same lesion during the same session would not be appropriate.

Ablation procedures are reported without a reduced services modifier 52, even if all three components (pre-dilation, post-dilation or guide wire passage) are not performed during the same session.

Placement of Stent

Revised code descriptor language for placement of an endoscopic stent in the esophagus states “pre-and postdilation and guide wire passage, when performed”. Code 43266, EGD with placement of stent is reported without a reduced services modifier 52, even if all three components (pre-dilation, post-dilation, and guide wire passage) are not performed during the same session.

Separate reporting of pre-dilation, post-dilation or guide wire passage of the same lesion during the same session would not be appropriate.

GI PROCEDURES

The key to accurately coding endoscopic procedures depends on knowing exactly what the surgeon did and the final destination of the scope.

A “Separate Site”, for definition purposes, can be a separation between lesions of 1 centimeter.

• Esophagogastroduodenoscopy (EGD) Procedures

Code 43239 – Biopsy – most common procedure – also use for CLO test or H.pylori test

Code 43255 – Control of Bleeding – don’t bill unless pt. came in with Bleed of has Post-OP Bleed

• Upper GI Dilations

Code 43248 – Savory Dilation – uses a Guidewire

Code 43450 – Maloney Dilation-Unguided

Code 43249 – Balloon Dilatio

QUESTION: Is there a difference regarding the use of modifiers 52 and 53 with regards to upper and lower endoscopic procedures?

ANSWER: Yes.

X EGD procedures: To report esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent) or because significant situations preclude such exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier 52, if repeat examination is not planned, or modifier 53, if repeat examination is planned.

• Example: EGD is performed and a tube is placed into the stomach. The duodenum is not examined and there is no plan to perform repeat EGD to examine the duodenum. Report procedure with modifier 52.

• Example: EGD is performed for evaluation of GI bleeding; the stomach is full of blood and the duodenum is not examined. Plan to control bleeding, lavage stomach and repeat upper endoscopy. Report procedure with modifier 53.

Limitations

Colonoscopy is generally not covered for treating the following:

Chronic/stable irritable bowel syndrome (There are unusual exceptions in which colonoscopy may be done once to rule out organic disease.);

Chronic abdominal pain;

Acute limited diarrhea;

Hemorrhoids;

Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management;

Bright red rectal bleeding in patient with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source;

Fulminant colitis;

Possible perforated viscus; or

Acute severe diverticulitis.

Coverage Limitations for EGD(s)

Distress that is chronic, non-progressive, atypical for known organic disease and is considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy).

Uncomplicated heartburn responding to medical therapy.

Metastatic adenocarcinoma of unknown primary site when the results will not alter management. X-ray findings of:

Asymptomatic or uncomplicated sliding hiatus hernia.

Uncomplicated duodenal bulb ulcer that has responded to therapy.

Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.

Routine screening of the upper gastrointestinal tract, without current gastrointestinal symptoms, about to undergo elective surgery for non-upper gastrointestinal disease.

When lower GI endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.

ICD-10 Codes that Support Medical Necessity

B25.2 Cytomegaloviral pancreatitis

B37.81 Candidal esophagitis

C15.3 Malignant neoplasm of upper third of esophagus

C15.4 Malignant neoplasm of middle third of esophagus

C15.5 Malignant neoplasm of lower third of esophagus

C15.8 Malignant neoplasm of overlapping sites of esophagus

C15.9 Malignant neoplasm of esophagus, unspecified

C16.0 Malignant neoplasm of cardia

C16.1 Malignant neoplasm of fundus of stomach

C16.2 Malignant neoplasm of body of stomach

C16.3 Malignant neoplasm of pyloric antrum

C16.4 Malignant neoplasm of pylorus

C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified

C16.6 Malignant neoplasm of greater curvature of stomach, unspecified

C16.8 Malignant neoplasm of overlapping sites of stomach

C16.9 Malignant neoplasm of stomach, unspecified

C17.0 Malignant neoplasm of duodenum

C17.1 Malignant neoplasm of jejunum

C17.2 Malignant neoplasm of ileum

C17.3 Meckel's diverticulum, malignant

C17.8 Malignant neoplasm of overlapping sites of small intestine

C17.9 Malignant neoplasm of small intestine, unspecified

C22.0 Liver cell carcinoma

C22.2 Hepatoblastoma

C22.3 Angiosarcoma of liver

C22.4 Other sarcomas of liver

C22.7 Other specified carcinomas of liver

C22.8 Malignant neoplasm of liver, primary, unspecified as to type

C23 Malignant neoplasm of gallbladder

C24.0 Malignant neoplasm of extrahepatic bile duct

C24.1 Malignant neoplasm of ampulla of Vater

C24.8 Malignant neoplasm of overlapping sites of biliary tract

C24.9 Malignant neoplasm of biliary tract, unspecified

C25.0 Malignant neoplasm of head of pancreas

C25.1 Malignant neoplasm of body of pancreas

C25.2 Malignant neoplasm of tail of pancreas

C25.3 Malignant neoplasm of pancreatic duct

C25.4 Malignant neoplasm of endocrine pancreas

C25.7 Malignant neoplasm of other parts of pancreas

C25.8 Malignant neoplasm of overlapping sites of pancreas

C25.9 Malignant neoplasm of pancreas, unspecified

C26.9 Malignant neoplasm of ill-defined sites within the digestive system